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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 05/14/2024
Date Signed: 05/15/2024 09:41:08 AM


Document Has Been Signed on 05/15/2024 09:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUMMERFIELD OF STOCKTONFACILITY NUMBER:
392700644
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
740
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(209) 951-6500
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:60CENSUS: 56DATE:
05/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:L. AndersonTIME COMPLETED:
03:10 PM
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Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident.

LPA reviewed special incident report dated 4/27/2024 stating R1 had an unwitnessed fall and as a result sustained a fractured hip.

R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has an updated service from 3/20/2024 based on the assessment R1 was independent with transferring.

After the fall and ER visit on 4/27/2024, R1 was discharged to a skilled facility for rehabilitation and will be assessed to return on 5/15/2024. R1 moved in on or about 12/20/2021 without any durable medical equipment.

During today's visit, LPA reviewed R1's file, medical records related to the fall and service plan which is dated 3/20/2024.


Exit interview was conducted with Staff.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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